Outcomes of a multifaceted intervention to prevent eclampsia and eclampsia-related deaths in Nigerian referral facilities

BACKGROUND

Eclampsia causes maternal mortality in Nigeria. This study presents the effectiveness of multifaceted interventions that addressed institutional barriers in reducing the incidence and case fatality rates associated with eclampsia.

METHODS

The design was quasi-experimental and the activities implemented at intervention hospitals included a new strategic plan, retraining health providers on eclampsia management protocols, clinical reviews of delivery care and educating pregnant women and their partners. Prospective data were collected monthly on eclampsia and related indicators from study sites over 2 y. The results were analysed by univariate, bivariate and multivariable logistic regression.

RESULTS

The results show a higher eclampsia rate (5.88% vs 2.45%) and a lower use of partograph and antenatal care (ANC; 17.99% vs 23.42%) in control compared with intervention hospitals, but similar case fatality rates of <1%. Overall, adjusted analysis shows a 63% decrease in the odds of eclampsia at intervention compared with control hospitals. Factors associated with eclampsia were ANC, referral for care from other facilities and older maternal age.

CONCLUSION

We conclude that multifaceted interventions that address challenges associated with managing pre-eclampsia and eclampsia in health facilities can reduce eclampsia occurrence in referral facilities in Nigeria and potential eclampsia death in resource-poor African countries.

The Effect of Body Mass Index on Post-Bolus Magnesium Levels in the Obstetric Patient

OBJECTIVE

 In the setting of a growing obese obstetric population, we sought to determine whether differences in body mass index (BMI) and obesity class influenced both serum magnesium levels and the likelihood of achieving therapeutic levels for eclampsia prophylaxis after standard boluses of magnesium sulfate.

STUDY DESIGN

 This is a retrospective cohort study of patients treated with magnesium sulfate in the setting of either preeclampsia with severe features or preterm labor between 2010 and 2016. Subjects were categorized by BMI: Normal (BMI < 30 kg/m2), Class 1 (BMI 30-34.9 kg/m2), Class 2 (BMI 35-39.9 kg/m2), and Class 3 (BMI ≥ 40 kg/m2). Study participants' demographics, intrapartum characteristics, and adverse reactions were compared among the groups. Logistic regression models were used to calculate unadjusted and adjusted odds ratios comparing the likelihood of each BMI class reaching therapeutic eclamptic prophylactic levels. Linear regression models were also evaluated to determine the relationship between BMI and post-bolus serum magnesium levels.

RESULTS

 Of the 760 people who met the inclusion criteria, 313 (41.1%) had normal BMI, 190 (25.0%) had Class 1 obesity, 135 (17.8%) had Class 2 obesity, and 122 (16.1%) had Class 3 obesity. When adjusted for confounders, those with Class 1 obesity were 54% less likely to achieve serum levels deemed therapeutic for seizure prophylaxis compared with normal BMI counterparts. Meanwhile, those with Class 2 or 3 obesity were 90% less likely. Linear regression models also demonstrated an inverse association between BMI and post-bolus serum magnesium levels.

CONCLUSION

 Increasing BMI has a significant effect on post-bolus serum magnesium levels regardless of standard loading dose used. Immediately after bolus administration, obese gravidas are significantly less likely to reach levels effective for eclamptic seizure prophylaxis. When considering which bolus to administer in an obese gravida, it may be more beneficial to choose a 6 g load.

KEY POINTS

· BMI has an inverse relationship with post-bolus serum magnesium levels.. · Obese gravidas were less likely to reach eclampsia prophylaxis levels regardless of bolus type.. · Obesity class, not just the presence or absence of obesity, plays a role in serum magnesium levels..

Eclampsia reduction with maternal early warning trigger tool

OBJECTIVES

To observe the incidence of eclampsia before and after implementing Maternal Early Warning Trigger (MEWT) tool.

STUDY DESIGN

A retrospective observational study to evaluate the effect of introduction of MEWT tool in a tertiary referral center with 10,000 annual births. Two epochs of five years duration were compared before and after implementing MEWT tool. MEWT tool has triggers for early identification of clinical deterioration and pathways for four most important maternal morbidity causes including hypertension. Hypertension pathway has emphasis on rapid control of severe acute hypertension, lab tests and magnesium sulfate prophylaxis. All pregnant women who registered and delivered at the study institute were included.

MAIN OUTCOMES MEASURES

Primary outcome was effect of MEWT tool on the incidence of eclampsia. A subset analysis was done to study the effect of MEWT tool on maternal and perinatal outcomes in women with hypertensive disease. Maternal ICU admissions, HELLP, pulmonary oedema, intracranial bleed and maternal deaths, and perinatal mean birthweight and gestational age, NICU admissions, prematurity, stillbirths, and neonatal deaths were compared.

RESULTS

The study period had 37,043 and 45,637 women in pre- and post-MEWT periods. The incidence of eclampsia reduced by 45.4 % from 1.1 to 0.6 per 1000 women (p 0.001). The most significant reduction was seen with antepartum eclampsia (0.8 to 0.3 per 1000, p = 0.02). There was significant reduction in all maternal and perinatal outcomes in women with hypertensive disorders (3,506 and 6,016 in pre- and post- MEWT periods) after introduction of MEWT tool.

CONCLUSION

Integrating the MEWT tool into the obstetric practice helps in reducing the incidence of eclampsia and improving maternal and fetal outcomes.

Medicaid expansion and risk of eclampsia

BACKGROUND

Eclampsia is an indicator of severe maternal morbidity and can be prevented through increased prenatal care access and early prenatal care utilization. The 2014 Medicaid expansion under the Patient Protection and Affordable Care Act allowed states to expand Medicaid coverage to nonelderly adults with incomes up to 138% of the federal poverty level. Its implementation has led to a significant increase in prenatal care access and utilization.

OBJECTIVE

This study aimed to assess the association of Medicaid expansion under the Affordable Care Act with eclampsia incidence.

STUDY DESIGN

This natural experiment study was based on US birth certificate data from January 2010 to December 2018 in 16 states that expanded Medicaid in January 2014 and in 13 states that did not expand Medicaid during the study period. The outcome was eclampsia incidence, the intervention was the implementation of the Medicaid expansion, and the exposure was state expansion status. Using the interrupted time series method, we compared temporal trends in the incidence of eclampsia before and after the intervention in expansion vs non-expansion states with adjustments for patient and hospital county characteristics.

RESULTS

Of the 21,570,021 birth certificates analyzed, 11,433,862 (53.0%) were in expansion states and 12,035,159 (55.8%) were in the postintervention period. The diagnosis of eclampsia was recorded in 42,677 birth certificates or 19.8 per 10,000 (95% confidence interval, 19.6-20.0). The incidence of eclampsia was higher for Black people (29.1 per 10,000) than for White (20.7 per 10,000), Hispanic (15.3 per 10,000), and birthing people of other race and ethnicity (15.4 per 10,000). In the expansion states, the incidence of eclampsia increased during the preintervention period and decreased during the postintervention period; in the nonexpansion states, a reverse pattern was observed. A statistically significant difference was observed between expansion and nonexpansion states in temporal trends between the pre- and postintervention periods, with an overall 1.6% decrease (95% confidence interval, 1.3-1.9) in the incidence of eclampsia in expansion states compared with nonexpansion states. The results were consistent in subgroup analyses according to maternal race and ethnicity, education level (less than high school or high school and higher), parity (nulliparous or parous), delivery mode (vaginal or cesarean delivery), and poverty in the residence county (high or low).

CONCLUSION

Implementation of the Affordable Care Act Medicaid expansion was associated with a small statistically significant reduction in the incidence of eclampsia. Its clinical significance and cost-effectiveness remain to be determined.

International Academy of Perinatal Medicine (IAPM) guidelines for screening, prediction, prevention and management of pre-eclampsia to reduce maternal mortality in developing countries

Approximately 800 women die from pregnancy or childbirth-related complications around the world every day, 99% of which occur in developing countries. In majority of cases deaths are related to pre-eclampsia and eclampsia. The purpose of new adjusted and simplified IAPM guidelines is specifically lowering maternal mortality by decreasing preventable deaths in developing countries (particularly in remote rural areas) by using rather cheap medicines used to control chronic and gestational hypertension, prevent pre-eclampsia in high-risk pregnancies and treat severe pre-eclampsia and eclampsia. IAPM guidelines should be implemented and evaluated in each developing country respecting specific problems, needs and resources. It is of essential importance to: 1. Identify specific high-risk pregnancies, 2. Commence timely appropriate ASA and calcium supplementation, 3. Organize basic antenatal care and adequate referral of pregnancies with early onset of pre-eclampsia to the appropriate institutions and ensure induction of labour in well-equipped delivery facility for women with near-term and term pre-eclampsia 4. Ensure magnesium sulphate availability to prevent severe pre-eclampsia and eclampsia-related maternal deaths, and 5. Identify specific barriers for implementation of these guidelines and correct them accordingly. Only by systematic implementations of these guidelines, we may have a chance to decrease the mortality of pre-eclampsia an its complications as a killer number one of mothers in developing countries.

Preeclampsia knowledge among postpartum women treated for preeclampsia and eclampsia at Korle Bu Teaching Hospital in Accra, Ghana

BACKGROUND

Preeclampsia/eclampsia is a major cause of maternal morbidity and mortality worldwide, yet patients' perspectives about their diagnosis are not well understood. Our study examines patient knowledge among women with preeclampsia/eclampsia in a large urban hospital in Ghana.

METHODS

Postpartum women diagnosed with preeclampsia or eclampsia were asked to complete a survey 2-5 days after delivery that assessed demographic information, key obstetric factors, and questions regarding provider counseling. Provider counseling on diagnosis, causes, complications, and future health effects of preeclampsia/eclampsia was quantified on a 4-point scale ('Counseling Composite Score'). Participants also completed an objective knowledge assessment regarding preeclampsia/eclampsia, scored from 0 to 22 points ('Preeclampsia/Eclampsia Knowledge Score' (PEKS)). Linear regression was used to identify predictors of knowledge score.

RESULTS

A total of 150 participants were recruited, 88.7% (133) with preeclampsia and 11.3% (17) with eclampsia. Participants had a median age of 32 years, median parity of 2, and mean number of 5.4 antenatal visits. Approximately half of participants reported primary education as their highest level of education. While 74% of women reported having a complication during pregnancy, only 32% of participants with preeclampsia were able to correctly identify their diagnosis, and no participants diagnosed with eclampsia could correctly identify their diagnosis. Thirty-one percent of participants reported receiving no counseling from providers, and only 11% received counseling in all four categories. Even when counseled, 40-50% of participants reported incomplete understanding. Out of 22 possible points on a cumulative knowledge assessment scale, participants had a mean score of 12.9 ± 0.38. Adjusting for age, parity, and the number of antenatal visits, higher scores on the knowledge assessment are associated with more provider counseling (β 1.4, SE 0.3, p < 0.001) and higher level of education (β 1.3, SE 0.48, p = 0.008).

CONCLUSIONS

Counseling by healthcare providers is associated with higher performance on a knowledge assessment about preeclampsia/eclampsia. Patient knowledge about preeclampsia/eclampsia is important for efforts to encourage informed healthcare decisions, promote early antenatal care, and improve self-recognition of warning signs-ultimately improving morbidity and reducing mortality.

Antenatal magnesium sulfate treatment and risk of necrotizing enterocolitis in preterm infants born at less than 32 weeks of gestation

Antenatal magnesium sulfate (MgSO4) treatment is widely used for fetal neuroprotection in women at risk of preterm delivery. However, some studies have recently suggested that in utero MgSO4 exposure is associated with an increased risk of necrotizing enterocolitis (NEC). This study aimed to investigate the association between antenatal MgSO4 treatment and risk of NEC. This retrospective cohort study included 756 infants born at 24‒31 weeks' gestation. Subjects were classified into three groups: period 1, when MgSO4 treatment protocol for fetal neuroprotection was not adopted (n = 267); period 2, when the protocol was adopted (n = 261); and period 3, when the protocol was withdrawn because of concern of risk of NEC (n = 228). Rates of NEC (≥ stage 2b) were analyzed according to time period and exposure to antenatal MgSO4. Significant difference in the rate of NEC was not found across the three time periods (2.6% vs. 6.5% vs. 4.8% in periods 1, 2 and 3, respectively, p = 0.103). The rate of NEC was comparable between the infants exposed and unexposed to antenatal MgSO4 (5.1% vs. 3.6%, p = 0.369). These results showed that antenatal MgSO4 treatment was not associated with risk of NEC in our study population.

Severe pre-eclamptic women with headache: is posterior reversible encephalopathy syndrome an associated concurrent finding?

BACKGROUND

A high incidence of posterior reversible encephalopathy syndrome (PRES) has been observed in women with eclampsia on imaging. However this association was documented mostly after convulsions occurred. This study aimed to detect the development of PRES using magnetic resonance imaging (MRI) in women with severe preeclampsia and headache, and evaluate the clinical and radiological findings in obstetric outcomes.

METHODS

A prospective single-center cohort study comprising 20 pregnant women with severe pre-eclampsia related headache was conducted using Numeric Rating Scale (NRS) score of ≧4. Additionally, non-contrast brain MRI was used to detect PRES and related radiological central nervous system (CNS) abnormalities.

RESULTS

Patients were enrolled at a mean gestational age of 32 weeks (range 29-38 weeks). Two women were unable to complete the scanning. Of the 18 MRI scans, 15 (83%) revealed abnormal findings. One patient developed an altered mental state and diffuse PRES, with the occipital, temporal, thalamus, and basal ganglia, the brain stem, and the cerebellum being affected. Two patients had abnormal susceptibility-weighted imaging (SWI) findings, indicating micro-hemorrhages. The majority (12 cases, 66%) of the patients had abnormal cortical hyperintensities in the occipital and temporal lobes. Only three patients had normal MRI pictures. None of the women had eclampsia occurred during the peripartum period, and only one unrelated neonatal death due to congenital anomalies.

CONCLUSION

A high incidence of abnormal cortical hyperintensity changes at locations typical for PRES on MRI was noted in women with severe pre-eclampsia and headache. These early hypertensive neurological signs allowed prompt and efficient obstetrical management, to prevent the development of eclampsia and PRES.

Antenatal magnesium sulphate and adverse neonatal outcomes: A systematic review and meta-analysis

BACKGROUND

There is widespread, increasing use of magnesium sulphate in obstetric practice for pre-eclampsia, eclampsia, and preterm fetal neuroprotection; benefit for preventing preterm labour and birth (tocolysis) is unproven. We conducted a systematic review and meta-analysis to assess whether antenatal magnesium sulphate is associated with unintended adverse neonatal outcomes.

METHODS AND FINDINGS

CINAHL, Cochrane Library, LILACS, MEDLINE, Embase, TOXLINE, and Web of Science, were searched (inceptions to 3 September 2019). Randomised, quasi-randomised, and non-randomised trials, cohort and case-control studies, and case reports assessing antenatal magnesium sulphate for pre-eclampsia, eclampsia, fetal neuroprotection, or tocolysis, compared with placebo/no treatment or a different magnesium sulphate regimen, were included. The primary outcome was perinatal death. Secondary outcomes included pre-specified and non-pre-specified adverse neonatal outcomes. Two reviewers screened 5,890 articles, extracted data, and assessed risk of bias following Cochrane Handbook and RTI Item Bank guidance. For randomised trials, pooled risk ratios (RRs) or mean differences, with 95% confidence intervals (CIs), were calculated using fixed- or random-effects meta-analysis. Non-randomised data were tabulated and narratively summarised. We included 197 studies (40 randomised trials, 138 non-randomised studies, and 19 case reports), of mixed quality. The 40 trials (randomising 19,265 women and their babies) were conducted from 1987 to 2018 across high- (16 trials) and low/middle-income countries (23 trials) (1 mixed). Indications included pre-eclampsia/eclampsia (24 trials), fetal neuroprotection (7 trials), and tocolysis (9 trials); 18 trials compared magnesium sulphate with placebo/no treatment, and 22 compared different regimens. For perinatal death, no clear difference in randomised trials was observed between magnesium sulphate and placebo/no treatment (RR 1.01; 95% CI 0.92 to 1.10; 8 trials, 13,654 babies), nor between regimens. Eleven of 138 non-randomised studies reported on perinatal death. Only 1 cohort (127 babies; moderate to high risk of bias) observed an increased risk of perinatal death with >48 versus ≤48 grams magnesium sulphate exposure for tocolysis. No clear secondary adverse neonatal outcomes were observed in randomised trials, and a very limited number of possible adverse outcomes warranting further consideration were identified in non-randomised studies. Where non-randomised studies observed possible harms, often no or few confounders were controlled for (moderate to high risk of bias), samples were small (200 babies or fewer), and/or results were from subgroup analyses. Limitations include missing data for important outcomes across most studies, heterogeneity of included studies, and inclusion of published data only.

CONCLUSIONS

Our findings do not support clear associations between antenatal magnesium sulphate for beneficial indications and adverse neonatal outcomes. Further large, high-quality studies (prospective cohorts or individual participant data meta-analyses) assessing specific outcomes, or the impact of regimen, pregnancy, or birth characteristics on these outcomes, would further inform safety recommendations. PROSPERO: CRD42013004451.

Management of Pre-eclampsia and Eclampsia: A Simulation

INTRODUCTION

Pre-eclampsia is a hypertensive disorder in pregnancy. Maternal sequelae that may occur include impaired liver function, disseminated intravascular coagulation, seizures (eclampsia), stroke, and death. Thus, providers should know how to recognize (diagnose) and treat pre-eclampsia and eclampsia.

METHODS

A simulator with noninvasive blood pressure monitoring was used. Transducers for fetal heart rate and contraction monitoring were placed on the simulator, which represented the patient. After obtaining a history and performing a physical examination, resident physician (postgraduate years 1-4) and nurse learners had to diagnose pre-eclampsia and treat this condition. They also had to treat severe-range blood pressures and manage eclampsia. Learner performance was assessed with a checklist. Debriefing followed the simulation.

RESULTS

Thirty resident learners participated in the study. Nurses did not participate. All resident learners indicated familiarity with the diagnosis and management of pre-eclampsia and emergent hypertension and managed these conditions correctly. All resident learners reported not being confident in managing eclampsia. None of the learners were able to stop the eclamptic seizure. All resident learners were more confident in managing eclampsia after the scenario compared with before (mean confidence level 3.6 ± 0.5 vs. 1.1 ± 0.4, p < .001).

DISCUSSION

Resident learners were familiar with the management of pre-eclampsia and emergent hypertension but not with eclampsia. We recommend that eclampsia simulations occur in a laboratory and in situ on the labor and delivery floor with interprofessional team members including obstetricians, nurses, anesthesiologists, emergency and family medicine physicians, nurse practitioners, and physician assistants.

Serum magnesium levels during magnesium sulfate infusion at 1 gram/hour versus 2 grams/hour as a maintenance dose to prevent eclampsia in women with severe preeclampsia: A randomized clinical trial

BACKGROUND

Magnesium sulfate is the ideal drug for the prevention and treatment of eclampsia. Nevertheless, the best regimen for protection against eclampsia with minimal side effects remains to be established. This study aimed to compare serum magnesium levels during intravenous infusion of magnesium sulfate at 1 gram/hour versus 2 grams/hour as a maintenance dose to prevent eclampsia in pregnant and postpartum women with severe preeclampsia.

METHODS

A randomized, triple-blind clinical trial was conducted, comparing serum magnesium levels during the intravenous infusion of magnesium sulfate at 1 gram/hour versus 2 grams/hour as a maintenance dose for the prevention of eclampsia in 62 pregnant and postpartum women with severe preeclampsia, 31 in each group. An intravenous loading dose of 6 grams of magnesium sulfate was administered over 30 minutes in both groups. The patients were then randomized to receive a maintenance dose of either 1 or 2 grams/hour for 24 hours. Primary outcomes consisted of serum magnesium levels at the following time points: baseline, 30 minutes, every 2 hours until the end of the first 6 hours, and every 6 hours thereafter until the termination of magnesium sulfate infusion. Side effects, maternal complications, and neonatal outcomes were the secondary outcomes.

RESULTS

Serum magnesium levels were higher in the 2-gram/hour group, with a statistically significant difference from 2 hours after the beginning of the magnesium sulfate infusion (P <.05). Oliguria was the most common complication recorded in both groups, with no significant difference between the 2 regimens (RR 0.88; 95% CI: 0.49-1.56; P = .65). No cases of eclampsia occurred. Side effects were more common in the 2-gram/hour group (RR 1.89; 95% CI: 1.04-3.41; P = .02); however, all were mild. There were no differences between the 2 groups regarding neonatal outcomes, except for admission to neonatal intensive care, which was more frequent in the 1-gram/hour group (25% vs 6.3%; P = .04).

CONCLUSION

Magnesium sulfate therapy at the maintenance dose of 1 gram/hour was just as effective as the 2-gram maintenance dose, with fewer side effects.

Automated early detection of obstetric complications: theoretic and methodologic considerations

Compared with adults who are admitted to general medical-surgical wards, women who are admitted to labor and delivery services are at much lower risk of experiencing unexpected critical illness. Nonetheless, critical illness and other complications that put either the mother or fetus at risk do occur. One potential approach to prevention is to use automated early warning systems, such as those used for nonpregnant adults. Predictive models that use data extracted in real time from electronic records constitute the cornerstone of such systems. This article addresses several issues that are involved in the development of such predictive models: specification of temporal characteristics, choice of denominator, selection of outcomes for model calibration, potential uses of existing adult severity of illness scores, approaches to data processing, statistical considerations, validation, and options for instantiation. These have not been addressed explicitly in the obstetrics literature, which has focused on the use of manually assigned scores. In addition, this article provides some results from work in progress to develop 2 obstetric predictive models with the use of data from 262,071 women who were admitted to a labor and delivery service at 15 Kaiser Permanente Northern California hospitals between 2010 and 2017.

Delivery or expectant management for prevention of adverse maternal and neonatal outcomes in hypertensive disorders of pregnancy: an individual participant data meta-analysis

OBJECTIVE

Hypertensive disorders affect 3-10% of pregnancies. Delayed delivery carries maternal risks, while early delivery increases fetal risk, so appropriate timing is important. The aim of this study was to compare immediate delivery with expectant management for prevention of adverse maternal and neonatal outcomes in women with hypertensive disease in pregnancy.

METHODS

CENTRAL, PubMed, MEDLINE and ClinicalTrials.gov were searched for randomized controlled trials comparing immediate delivery to expectant management in women presenting with gestational hypertension or pre-eclampsia without severe features from 34 weeks of gestation. The primary neonatal outcome was respiratory distress syndrome (RDS) and the primary maternal outcome was a composite of HELLP syndrome and eclampsia. The PRISMA-IPD guideline was followed and a two-stage meta-analysis approach was used. Relative risks (RR) and numbers needed to treat or harm (NNT/NNH) with 95% CI were calculated to evaluate the effect of the intervention.

RESULTS

Main outcomes were available for 1724 eligible women. Compared with expectant management, immediate delivery reduced the composite risk of HELLP syndrome and eclampsia in all women (0.8% vs 2.8%; RR, 0.33 (95% CI, 0.15-0.73); I2  = 0%; NNT, 51 (95% CI, 31.1-139.3)) as well as in the pre-eclampsia subgroup (1.1% vs 3.5%; RR, 0.39 (95% CI, 0.15-0.98); I2  = 0%). Immediate delivery increased RDS risk (3.4% vs 1.6%; RR, 1.94 (95% CI 1.05-3.6); I2  = 24%; NNH, 58 (95% CI, 31.1-363.1)), but depended upon gestational age. Immediate delivery in the 35th week of gestation increased RDS risk (5.1% vs 0.6%; RR, 5.5 (95% CI, 1.0-29.6); I2  = 0%), but immediate delivery in the 36th week did not (1.5% vs 0.4%; RR, 3.4 (95% CI, 0.4-30.3); I2 not applicable).

CONCLUSION

In women with hypertension in pregnancy, immediate delivery reduces the risk of maternal complications, whilst the effect on the neonate depends on gestational age. Specifically, women with a-priori higher risk of progression to HELLP, such as those already presenting with pre-eclampsia instead of gestational hypertension, were shown to benefit from earlier delivery. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Preventing deaths due to the hypertensive disorders of pregnancy

In this chapter, taking a life cycle and both civil society and medically oriented approach, we will discuss the contribution of the hypertensive disorders of pregnancy (HDPs) to maternal, perinatal and newborn mortality and morbidity. Here we review various interventions and approaches to preventing deaths due to HDPs and discuss effectiveness, resource needs and long-term sustainability of the different approaches. Societal approaches, addressing sustainable development goals (SDGs) 2.2 (malnutrition), 3.7 (access to sexual and reproductive care), 3.8 (universal health coverage) and 3c (health workforce strengthening), are required to achieve SDGs 3.1 (maternal survival), 3.2 (perinatal survival) and 3.4 (reduced impact of non-communicable diseases (NCDs)). Medical solutions require greater clarity around the classification of the HDPs, increased frequency of effective antenatal visits, mandatory responses to the HDPs when encountered, prompt provision of life-saving interventions and sustained surveillance for NCD risk for women with a history of the HDPs.

Inter-pregnancy interval and risk of recurrent pre-eclampsia: systematic review and meta-analysis

BACKGROUND

Women with a history of pre-eclampsia have a higher risk of developing pre-eclampsia in subsequent pregnancies. However, the role of the inter-pregnancy interval on this association is unclear.

OBJECTIVE

To explore the effect of inter-pregnancy interval on the risk of recurrent pre-eclampsia or eclampia.

SEARCH STRATEGY

MEDLINE, EMBASE and LILACS were searched (inception to July 2015).

SELECTION CRITERIA

Cohort studies assessing the risk of recurrent pre-eclampsia in the immediate subsequent pregnancy according to different birth intervals.

DATA COLLECTION AND ANALYSIS

Two reviewers independently performed screening, data extraction, methodological and quality assessment. Meta-analysis of adjusted odds ratios (aOR) with 95 % confidence intervals (CI) was used to measure the association between various interval lengths and recurrent pre-eclampsia or eclampsia.

MAIN RESULTS

We identified 1769 articles and finally included four studies with a total of 77,561 women. The meta-analysis of two studies showed that compared to inter-pregnancy intervals of 2-4 years, the aOR for recurrent pre-eclampsia was 1.01 [95 % CI 0.95 to 1.07, I(2) 0 %] with intervals of less than 2 years and 1.10 [95 % CI 1.02 to 1.19, I(2) 0 %] with intervals longer than 4 years.

CONCLUSION

Compared to inter-pregnancy intervals of 2 to 4 years, shorter intervals are not associated with an increased risk of recurrent pre-eclampsia but longer intervals appear to increase the risk. The results of this review should be interpreted with caution as included studies are observational and thus subject to possible confounding factors.

Pyridoxine (vitamin B6) supplementation during pregnancy or labour for maternal and neonatal outcomes

BACKGROUND

Vitamin B6 plays vital roles in numerous metabolic processes in the human body, such as nervous system development and functioning. It has been associated with some benefits in non-randomised studies, such as higher Apgar scores, higher birthweights, and reduced incidence of pre-eclampsia and preterm birth. Recent studies also suggest a protection against certain congenital malformations.

OBJECTIVES

To evaluate the clinical effects of vitamin B6 supplementation during pregnancy and/or labour.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (31 March 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials comparing vitamin B6 administration in pregnancy and/or labour with: placebos, no supplementations, or supplements not containing vitamin B6.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. For this update, we assessed methodological quality of the included trials using risk of bias and the GRADE approach.

MAIN RESULTS

Four trials (1646 women) were included. The method of randomisation was unclear in all four trials and allocation concealment was reported in only one trial. Two trials used blinding of participants and outcomes. Vitamin B6 as oral capsules or lozenges resulted in decreased risk of dental decay in pregnant women (capsules: risk ratio (RR) 0.84; 95% confidence interval (CI) 0.71 to 0.98; one trial, n = 371, low quality of evidence; lozenges: RR 0.68; 95% CI 0.56 to 0.83; one trial, n = 342, low quality of evidence). A small trial showed reduced mean birthweights with vitamin B6 supplementation (mean difference -0.23 kg; 95% CI -0.42 to -0.04; n = 33; one trial). We did not find any statistically significant differences in the risk of eclampsia (capsules: n = 1242; three trials; lozenges: n = 944; one trial), pre-eclampsia (capsules n = 1197; two trials, low quality of evidence; lozenges: n = 944; one trial, low-quality evidence) or low Apgar scores at one minute (oral pyridoxine: n = 45; one trial), between supplemented and non-supplemented groups. No differences were found in Apgar scores at five minutes, or breastmilk production between controls and women receiving oral (n = 24; one trial) or intramuscular (n = 24; one trial) loading doses of pyridoxine at labour. Overall, the risk of bias was judged as unclear. The quality of the evidence using GRADE was low for both pre-eclampsia and dental decay. The other primary outcomes, preterm birth before 37 weeks and low birthweight, were not reported in the included trials.

AUTHORS' CONCLUSIONS

There were few trials, reporting few clinical outcomes and mostly with unclear trial methodology and inadequate follow-up. There is not enough evidence to detect clinical benefits of vitamin B6 supplementation in pregnancy and/or labour other than one trial suggesting protection against dental decay. Future trials assessing this and other outcomes such as orofacial clefts, cardiovascular malformations, neurological development, preterm birth, pre-eclampsia and adverse events are required.

[Eclampsias have declined in Finland between 2006 and 2010]

BACKGROUND

We surveyed the occurrence of eclampsia in Finland since the time when the use of magnesium sulfate became more common.

MATERIALS AND METHODS

We found a total of 46 persons with eclampsia diagnosis from two registers between 2006 and 2010.

RESULTS

The occurrence of eclampsia was 1.5/10 000 childbirths. None of the mothers died, but severe complications occurred in 76% of the cases.

CONCLUSIONS

The decline in occurrence of eclampsia, recurrence of seizures and severe prolonged complications in Finland is likely to be partly associated with the increased use of magnesium sulfate. Some risk patients continue to remain undetected.

[HELLP syndrome]

HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) is a relatively rare complication of pregnancy. It usually develops in the IIId trimester or after delivery. HELLP syndrome is associated with increased maternal (placental abruption, disseminated intravascular coagulation, hepatic hematomas and rupture, and acute kidney injury) and neonatal (prematurity, low birth weight) risk complications. In this article the diagnosis, clinical picture and treatment of this disease have been shortly reviewed.

[Iron metabolism in women with anemia and eclampsia (Part I)]

The review deals with a modern view of iron exchange in general and during pregnancy, in particular Different views on the mechanisms of the development of anemia in pregnancy are reflected. The protective role of anemia is noted, and also the opinion of the review authors to the negative role of prophylactic supplementation of iron is reflected. Are numerous and compelling scientific evidence pointing to the large number of negative prevention of iron. That questioned the usefulness of routine appointments for pregnant women with iron. According to a large number of studies assigning pregnant iron on the one hand, contributes to excessive activation of free radical oxidation, the accumulation of lipid peroxidation products and demonstrations of eclampsia, and from the other potentiates the bacterial aggression and development of purulent-septic diseases that generally leads to the development of complications in pregnancy.

[Preeclampsia and benefit form magnesium sulfate. About 105 cases]

OBJECTIVES

The aim of this study was to determine the amount of magnesium sulfate involved when we diagnose a severe preeclampsia in pregnant women. Other goals were to know what the MgSO4 side-effects and complications are, and what benefits this treatment brings to prevent an eclampsia.

PATIENTS AND METHODS

This retrospective and descriptive study was conducted for 7 years. We identified 105 women treated by MgSO4 out of 560 preeclampsia cases. To prevent eclampsia, those women were administrated MgSO4 before, during or after labor. All data about hospitalization term and MgSO4 term administration were collected in order to understand if MgSO4 side-effects for the women and the fetus occurred before, during or after labor. Those tables are compared with the MgSO4 administered dosages.

RESULTS

MgSO4 isn't systematically used in all the preeclampsia cases. Forty percent of women under treatment presented low side effects. Overdoses, encountered in 31.4% of cases, regressed as soon as the MgSO4's perfusion was stopped. No major complications were noted. Only 0.95% of women treated by MgSO4 presented an eclampsia.

DISCUSSION AND CONCLUSION

MgSO4 administered only to women having a neurological preeclampsia, within therapeutic doses and with rigorous monitoring, does not bring deleterious effects to the mother or newborn baby. Consequently, MgSO4's benefits were above the risks.

Maternal adverse effects of different antenatal magnesium sulphate regimens for improving maternal and infant outcomes: a systematic review

BACKGROUND

Antenatal magnesium sulphate, widely used in obstetrics to improve maternal and infant outcomes, may be associated with adverse effects for the mother sufficient for treatment cessation. This systematic review aimed to quantify maternal adverse effects attributed to treatment, assess how adverse effects vary according to different regimens, and explore women's experiences with this treatment.

METHODS

Bibliographic databases were searched from their inceptions to July 2012 for studies of any design that reported on maternal adverse effects associated with antenatal magnesium sulphate given to improve maternal or infant outcomes. Primary outcomes were life-threatening adverse effects of treatment (death, cardiac arrest, respiratory arrest). For randomised controlled trials, data were meta-analysed, and risk ratios (RR) pooled using fixed-effects or random-effects models. For non-randomised studies, data were tabulated by design, and presented as RR, odds ratios or percentages, and summarised narratively.

RESULTS

A total of 143 publications were included (21 randomised trials, 15 non-randomised comparative studies, 32 case series and 75 reports of individual cases), of mixed methodological quality. Compared with placebo or no treatment, magnesium sulphate was not associated with an increased risk of maternal death, cardiac arrest or respiratory arrest. Magnesium sulphate significantly increased the risk of 'any adverse effects' overall (RR 4.62, 95% CI 2.42-8.83; 4 trials, 13,322 women), and treatment cessation due to adverse effects (RR 2.77; 95% CI 2.32-3.30; 5 trials, 13,666 women). Few subgroup differences were observed (between indications for use and treatment regimens). In one trial, a lower dose regimen (2 g/3 hours) compared with a higher dose regimen (5 g/4 hours) significantly reduced treatment cessation (RR 0.05; 95% CI 0.01-0.39, 126 women). Adverse effect estimates from studies of other designs largely supported data from randomised trials. Case reports supported an association between iatrogenic overdose of magnesium sulphate and life-threatening consequences.

CONCLUSIONS

Appropriate administration of antenatal magnesium sulphate was not shown to be associated with serious maternal adverse effects, though an increase in 'minor' adverse effects and treatment cessation was shown. Larger trials are needed to determine optimal regimens, achieving maximal effectiveness with minimal adverse effects, for each antenatal indication for use. Vigilance in the use of magnesium sulphate is essential for women's safety.

A shortened versus standard matched postpartum magnesium sulphate regimen in the treatment of eclampsia: a randomised controlled trial

Magnesium sulphate is currently the most ideal drug for the treatment of eclampsia but its use in Nigeria is still limited due its cost and clinicians inexperience with the drug. The purpose of this study was to determine whether a shortened postpartum course of magnesium sulphate is as effective as the standard Pritchard regimen in controlling fits in eclampsia Between January and June 2011, 98 eclamptic mothers presenting at the labour ward of the University of Maiduguri Teaching Hospital were randomised to receive either the standard Pritchard regimen of magnesium sulphate or a shortened postpartum course in which only two doses of intramuscular magnesium sulphate is given four hours apart. The maternal and fetal outcomes were compared. The primary outcome measure was recurrence of fits. The recurrence of fits and other maternal complications were similar in the two groups. The total dosage of magnesium sulphate in the shortened group was reduced by 40% in 66% of patients. The shortened postpartum course of magnesium sulphate is as effective as the standard Pritchard regimen in the management of eclampsia.

Antithrombotic therapy for improving maternal or infant health outcomes in women considered at risk of placental dysfunction

BACKGROUND

Pregnancy complications such as pre-eclampsia and eclampsia, intrauterine growth restriction and placental abruption are thought to have a common origin related to abnormalities in the development and function of the placenta.

OBJECTIVES

To compare, using the best available evidence, the benefits and harms of antenatal antithrombotic therapy to improve maternal or infant health outcomes in women considered at risk of placental dysfunction, when compared with other treatments, placebo or no treatment.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (17 July 2012).

SELECTION CRITERIA

Randomised controlled trials comparing antenatal antithrombotic therapy (either alone or in combination with other agents) with placebo or no treatment, or any other treatment in the antenatal period to improve maternal or infant health outcomes in women considered at risk of placental dysfunction.

DATA COLLECTION AND ANALYSIS

Two review authors evaluated trials under consideration for appropriateness for inclusion and methodological quality without consideration of their results according to the prestated eligibility criteria. We used a fixed-effect meta-analysis for combining study data if the trials were judged to be sufficiently similar. We investigated heterogeneity by calculating I² statistic, and if this indicated a high level of heterogeneity among the trials included, we used a random-effects model.

MAIN RESULTS

Our search strategy identified 18 reports of 14 studies for consideration. The original review included five studies (484 women) which met the inclusion criteria, with a further five studies included in the updated review, involving an additional 655 women. The overall quality of the included trials was considered fair to good.Nine studies compared heparin (alone or in combination with dipyridamole or low-dose aspirin) with no treatment; and one compared trapidil (triazolopyrimidine).While this review identified the use of heparin to be associated with a statistically significant reduction in risk of perinatal mortality (six studies; 653 women; risk ratio (RR) 0.40; 95% confidence intervals (CI) 0.20 to 0.78), preterm birth before 34 (three studies; 494 women; RR 0.46; 95% CI 0.29 to 0.73) and 37 (five studies; 621 women; RR 0.72; 95% CI 0.58 to 0.90) weeks' gestation, and infant birthweight below the 10th centile for gestational age (seven studies; 710 infants; RR 0.41; 95% CI 0.27 to 0.61), there is a lack of reliable information available related to clinically relevant, serious adverse infant health outcomes, which have not been reported to date.

AUTHORS' CONCLUSIONS

While treatment with heparin for women considered to be at particularly high risk of adverse pregnancy complications secondary to placental insufficiency was associated with a statistically significant reduction in risk of perinatal mortality, preterm birth before 34 and 37 weeks' gestation, and infant birthweight below the 10th centile for gestational age when compared with no treatment for women considered at increased risk of placental dysfunction, to date, important information about serious adverse infant and long-term childhood outcomes is unavailable.

Magnesium sulphate in management of severe pre-eclampsia and eclampsia

BACKGROUND

Pre-eclampsia and eclampsia (PE/E) are the second leading cause of maternal mortality in Nepal accounting for 21% of all maternal deaths and 30% of all facility based maternal deaths. For treatment of severe pre-eclampsia and eclampsia (SPE/E), WHO has identified magnesium sulphate (MgSO4) as the most effective and low cost medication. The objective of the study was to explore current situation of SPE/E management using MgSO4 in 10 health facilities of Mid Western Development Region.

METHODS

Descriptive and single group pre-test, post test study design was used for the study. Data were collected by reviewing records, taking interviews and through observation. Knowledge and skills of service provider was assessed and scored (0-100%) before and after the educational intervention.

RESULTS

One year records indicate that 0.5% SPE/E cases were found in Dang Sub Regional Hospital and Pyuthan District Hospital; 0.4% in Bheri Zonal Hospital; 0.9% in Mehelkuna PHCC and 0.5% in Rajapur PHCC. In most of the hospitals, these cases were managed with MgSO4. During pre-testing none of the health facility was able to get standard score (80%) but in post test, 50% health facilities were able to get 80% or higher score.

CONCLUSIONS

Establishing national standard and providing one-time training is not sufficient, it requires refresher onsite training for propermanagement of SPE/E on time to improve maternal and neonatal health.

[Pulmonary oedema--as first symptom of the postpartum cardiomyopathy. The role of cardiac MRI in diagnostic process]

We present a case of a 23 year-old pregnant woman, who underwent a cesarian section due to the risk of eclampsia. The patient developed pulmonary oedema due to severe left ventricular impairement. After the standard treatment and a short period of bromocriptine, the symptoms of the oedema subsided. In order to differentiate between the primary dilated cardiomyopathy and postpartum cardiomyopathy (PPC), the magnetic resonance imaging (MRI) examination was carried out twice at a 3-month interval, and confirmed the diagnosis of PPC. This case report underlines the role of MRI in detection of PPC.

Magnesium sulphate and other anticonvulsants for women with pre-eclampsia

BACKGROUND

Eclampsia, the occurrence of a seizure (fit) in association with pre-eclampsia, is rare but potentially life-threatening. Magnesium sulphate is the drug of choice for treating eclampsia. This review assesses its use for preventing eclampsia.

OBJECTIVES

To assess the effects of magnesium sulphate, and other anticonvulsants, for prevention of eclampsia.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (4 June 2010), and the Cochrane Central Register of Controlled Trials Register (The Cochrane Library 2010, Issue 3).

SELECTION CRITERIA

Randomised trials comparing anticonvulsants with placebo or no anticonvulsant, or comparisons of different drugs, for pre-eclampsia.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data independently.

MAIN RESULTS

We included 15 trials. Six (11,444 women) compared magnesium sulphate with placebo or no anticonvulsant: magnesium sulphate more than a halved the risk of eclampsia (risk ratio (RR) 0.41, 95% confidence interval (CI) 0.29 to 0.58; number needed to treat for an additional beneficial outcome (NNTB) 100, 95% CI 50 to 100), with a non-significant reduction in maternal death (RR 0.54, 95% CI 0.26 to 1.10) but no clear difference in serious maternal morbidity (RR 1.08, 95% CI 0.89 to 1.32). It reduced the risk of placental abruption (RR 0.64, 95% CI 0.50 to 0.83; NNTB 100, 95% CI 50 to 1000), and increased caesarean section (RR 1.05, 95% CI 1.01 to 1.10). There was no clear difference in stillbirth or neonatal death (RR 1.04, 95% CI 0.93 to 1.15). Side effects, primarily flushing, were more common with magnesium sulphate (24% versus 5%; RR 5.26, 95% CI 4.59 to 6.03; number need to treat for an additional harmful outcome (NNTH) 6, 95% CI 5 to 6).Follow-up was reported by one trial comparing magnesium sulphate with placebo: for 3375 women there was no clear difference in death (RR 1.79, 95% CI 0.71 to 4.53) or morbidity potentially related to pre-eclampsia (RR 0.84, 95% CI 0.55 to 1.26) (median follow-up 26 months); for 3283 children exposed in utero there was no clear difference in death (RR 1.02, 95% CI 0.57 to 1.84) or neurosensory disability (RR 0.77, 95% CI 0.38 to 1.58) at age 18 months.Magnesium sulphate reduced eclampsia compared to phenytoin (three trials, 2291 women; RR 0.08, 95% CI 0.01 to 0.60) and nimodipine (one trial, 1650 women; RR 0.33, 95% CI 0.14 to 0.77).

AUTHORS' CONCLUSIONS

Magnesium sulphate more than halves the risk of eclampsia, and probably reduces maternal death. There is no clear effect on outcome after discharge from hospital. A quarter of women report side effects with magnesium sulphate.

Magnesium sulphate versus phenytoin for eclampsia

BACKGROUND

Eclampsia, the occurrence of a seizure in association with pre-eclampsia, remains a rare but serious complication of pregnancy. A number of different anticonvulsants have been used to control eclamptic fits and to prevent further seizures.

OBJECTIVES

The objective of this review was to assess the effects of magnesium sulphate compared with phenytoin when used for the care of women with eclampsia. Magnesium sulphate is compared with diazepam and with lytic cocktail in other Cochrane reviews.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2010).

SELECTION CRITERIA

Randomised trials comparing magnesium sulphate (intravenous or intramuscular administration) with phenytoin for women with a clinical diagnosis of eclampsia.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial quality and extracted data.

MAIN RESULTS

We have included data from seven trials, involving 972 women. One large trial (775 women) was of good quality. Magnesium sulphate was associated with a substantial reduction in the recurrence of seizures, when compared to phenytoin (six trials, 972 women; risk ratio (RR) 0.34, 95% confidence interval (CI) 0.24 to 0.49). The trend in maternal mortality favours magnesium sulphate, but the difference does not reach statistical significance (three trials, 847 women; RR 0.50, 95% CI 0.24 to 1.05). There were reductions in the risk of pneumonia (one trial, RR 0.44, 95% CI 0.24 to 0.79), ventilation (one trial, RR 0.68, 95% CI 0.50 to 0.91) and admission to an intensive care unit (one trial, RR 0.67, 95% CI 0.50 to 0.89) associated with the use of magnesium sulphate rather than phenytoin.For the baby, magnesium sulphate was associated with fewer admissions to a special care baby unit (SCBU) (one trial, 518 babies; RR 0.73, 95% CI 0.58 to 0.91) and fewer babies who died or were in SCBU for more than seven days (one trial, 643 babies; RR 0.77, 95% CI 0.63 to 0.95) than phenytoin. There was no clear difference in perinatal deaths (two trials, 665 babies; (RR 0.85, 95% CI 0.67 to 1.09).

AUTHORS' CONCLUSIONS

Magnesium sulphate, rather than phenytoin, for women with eclampsia reduces the risk ratio of recurrence of seizures, probably reduces the risk of maternal death, and improves outcome for the baby. Magnesium sulphate is the drug of choice for women with eclampsia. The use of phenytoin should be abandoned.

Antithrombotic therapy for improving maternal or infant health outcomes in women considered at risk of placental dysfunction

BACKGROUND

Pregnancy complications such as pre-eclampsia and eclampsia, intrauterine growth restriction and placental abruption are thought to have a common origin related to abnormalities in the development and function of the placenta.

OBJECTIVES

To compare, using the best available evidence, the benefits and harms of antenatal antithrombotic therapy to improve maternal or infant health outcomes in women considered at risk of placental dysfunction, when compared with other treatments, placebo or no treatment.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2010).

SELECTION CRITERIA

Randomised controlled trials comparing antenatal antithrombotic therapy (either alone or in combination with other agents) with placebo or no treatment, or any other treatment in the antenatal period to improve maternal or infant health outcomes in women considered at risk of placental dysfunction.

DATA COLLECTION AND ANALYSIS

Two review authors evaluated trials under consideration for appropriateness for inclusion and methodological quality without consideration of their results according to the prestated eligibility criteria. We used a fixed-effect meta-analysis for combining study data if the trials were judged to be sufficiently similar. We investigated heterogeneity by calculating I(2) statistic, and if this indicated a high level of heterogeneity among the trials included we used a random-effects model.

MAIN RESULTS

Our search strategy identified 14 reports of 10 studies for consideration, of which five met the inclusion criteria, involving 484 women. Four studies compared heparin (alone or in combination with dipyridamole) with no treatment; and one compared trapidil (triazolopyrimidine). While there were no statistically significant differences identified for the primary outcomes following heparin treatment, it was associated with a reduction in the risk of pre-eclampsia, eclampsia, and infant birthweight less than the 10th centile for gestational age.

AUTHORS' CONCLUSIONS

The review identified no significant differences for the primary outcomes perinatal mortality, preterm birth less than 34 weeks' gestation, and childhood neurodevelopmental handicap, although the number of studies and participants was small. While treatment with heparin appears promising with a reduction in pre-eclampsia, eclampsia, and infant birthweight less than the 10th centile for gestational age, the number of studies and participants included was small, and to date important information about serious adverse infant and long-term childhood outcomes is unavailable. Further research is required.

Hypertension in pregnancy and women of childbearing age

Hypertension in women of childbearing age is a challenging medical problem with increasing prevalence. Essential hypertension remains the most common diagnosis in young women. Reproductive goals and possible teratogenic effects must be considered when initiating therapy. Hypertensive disorders of pregnancy are frequent causes of maternal/fetal morbidity and mortality, the most common being preeclampsia/eclampsia. Pregnant patients should be screened routinely. Early recognition and prompt care from a multidisciplinary service, including obstetrics, cardiology, and intensive medicine, are required to prevent deleterious outcomes. Hypertensive disorders of pregnancy reflect endometrial endothelial dysfunction/abnormalities and systemic endothelial dysfunction, which might predict future cardiovascular disease in these young women, prompting early preventive measures.

The Use of Standard Dose of Magnesium Sulphate in Prophylaxis of Eclamptic Seizures: Do Body Mass Index Alterations Have Any Effect on Success?

OBJECTIVE

We anticipated that the universal use of a standard magnesium sulfate infusion to prevent eclamptic convulsions in preeclamptic patients would result in alterations in circulating magnesium levels that were negatively correlated with the patient's body mass index. We postulated that the highest failure rate with seizure prophylaxis would occur in patients with the highest body mass index.

MATERIALS AND METHODS

After discarding 6 patients, this study was performed in 194 of 200 preeclamptic patients admitted to our high risk pregnancy unit between February 2000 and August 2000, who were divided into four groups determined by body mass indices. A standard magnesium sulfate infusion protocol (loading dose 4.5 g/15 minutes followed by 1.8 g/hour) was administered to 194 preeclamptic patients. One hundred and thirty-eight severe preeclamptic patients received magnesium sulfate during both antepartum and postpartum periods. The remaining 56 patients only received the therapy during the postpartum period. Serial serum magnesium levels of each groups were recorded and compared.

RESULTS

The 1.8 g infusion rate produced acceptable magnesium levels in the majority of patients but most were in the lower 50% of the therapeutic range. Levels were lowest in patients with high body mass indices (this group recorded most of the subtherapeutic levels, particularly when patient were infused antepartum). Apart from 13 referred patients who had convulsed prior to admission no eclampsia occurred during the antepartum period while seizures occurred in nine women during the postpartum period. Two hours after the initiation of the therapy, magnesium levels were inversely related to the body mass index (BMI) both during the ante- and postpartum periods (Prepartum; group I: 5.97 mg/dl, group II: 4.90 mg/dl, group III: 4.35 mg/dl, group IV: 3.88 mg/dl; Postpartum; group I: 5.89 mg/dl, group II: 5.71 mg/dl, group III: 4.82 mg/dl and group IV: 4.61 mg/dl, Table 4). Although the lowest levels were detected in patients with high body mass indices, in contrast to our hypothesis, eclamptic seizures occurred in four patients with low body mass indices. Furthermore therapeutic serum magnesium levels were detected in three of these patients. There was no association between treatment failures and body mass or with magnesium levels.

CONCLUSION

The infusion regimen described herein resulted in therapeutic levels in the majority of patients that correlated inversely with body mass index. However most levels fell within the lower range of what many studies consider "therapeutic" suggesting that maintenance infusion rates of at least 2-2.5 g/hour would be more appropriate. This would be particularly true in patients with body mass indices exceeding 30, where subtherapeutic levels occurred most frequently. The study's limited power prevents conclusions on outcomes but what is of interest is that eclamptic convulsions did not correlate with either body mass index or circulating plasma magnesium levels.

The valuation of prenatal life in economic evaluations of perinatal interventions

Perinatal interventions delivered during the prenatal period have the potential to directly impact prenatal life. The decision on when to begin 'counting' the life of an infant in the calculus has received little attention in previous economic evaluations of perinatal interventions. We illustrate, using data from a recent trial-based economic evaluation of magnesium sulphate given to women with pre-eclampsia to prevent eclampsia, how different definitions of when human life commences can have a significant impact upon cost-effectiveness estimates based on composite outcome measures such as life years or quality-adjusted life years gained or disability-adjusted life years averted. Further, we suggest ways in which methods in this area can be improved.

Extracellular calcium and magnesium in preeclampsia and eclampsia

The cause of preeclampsia remains unknown and calcium and magnesium supplement are being suggested as means of prevention. The objective of this study was to assess magnesium and calcium in the plasma and cerebrospinal fluid of Nigerian women with preeclampsia and eclampsia. Setting was University of Benin Teaching Hospital, in Nigeria. It was a cross-sectional study comprising of eleven patients and twenty-three controls. The mean, standard deviation and Standard Error of Mean (SEM) were calculated. Student 't' test method was applied. Plasma calcium was significantly lower in patients than controls (9.2 +/- 1.02 Vs 9.98 +/- 0.87mg/dl, P 0.043) "t" test. The CSF calcium and magnesium levels were lower in patients than controls, (5.66 +/- 1.22 vs 6.67 +/- 1.15 mg/ dl, P 0.043 and 1.75 +/- 0.56 vs 1.91 +/- 0.19 mg/dl, P 0. < 0.0001) respectively. There is extracellular calcium and magnesium reduction in patients with preeclampsia and eclampsia. This reduction may have a cause and effect relationship with these disorders.

[Late postpartum eclampsia]

A 36-year-old woman, who had given birth once before, had an eclamptic epileptic seizure eight days after caesarean delivery of healthy premature twins. Severe headache and loss of vision, leading to blindness, had not been recognised as prodromal signs by the healthcare professionals involved. Thereafter, she suffered a generalised epileptic seizure with tongue bite. She recovered fully after treatment with magnesium sulphate and nifedipine. Eclampsia is a severe condition with high rates of maternal complications, such as abruptio placentae, disseminated intravascular coagulation, neurological problems, pulmonary oedema, acute renal insufficiency and even death. Recognition of prodromal symptoms like headache, visual disturbances and upper abdominal pain is of the utmost importance. Magnesium sulphate intravenously is the treatment of choice. About 25% of the cases of postpartum eclampsia develop 2-28 days after delivery. A history of pre-eclampsia before or during the delivery is often absent. There is a relative increase in the incidence of late postpartum eclampsia, possibly because of misinterpretation ofprodromal symptoms, as illustrated by this case report. Every physician should be able to recognise the symptoms of pre-eclampsia and be aware of the possible consequences.

Selective magnesium sulfate prophylaxis for the prevention of eclampsia in women with gestational hypertension

OBJECTIVE

To describe the incidence of eclampsia in women with mild gestational hypertension when only women with severe gestational hypertension are given magnesium sulfate prophylaxis.

METHODS

This is a prospective 4(1/2)-year observational study. Those women who met our criteria for severe gestational hypertension received intravenous magnesium sulfate prophylaxis, and women with nonsevere hypertension did not. Data were collected at delivery to ascertain the incidence of eclampsia and maternal and neonatal morbidity.

RESULTS

A total of 72,004 women were delivered during the study period, 6,431 had gestational hypertension, 3,935 met the criteria for severe disease and were given magnesium sulfate prophylaxis, 2,496 women with nonsevere hypertension were not treated. Eighty-seven women developed eclampsia, for an overall incidence of 1 in 828 deliveries, a 50% increase when compared with 5 preceding years where all women with gestational hypertension were given magnesium sulfate prophylaxis. Of the 2,496 women with nonsevere hypertension who were not treated, 27 had eclampsia (1 in 92). Women with eclampsia were more likely to require general anesthesia for cesarean delivery compared with hypertensive women without eclampsia (23% versus 4%, P < .001), but they had no additional morbidity. Infants of eclamptic mothers had more adverse outcomes than those without convulsions (12% versus 1%, P < .04).

CONCLUSION

Selective magnesium sulfate prophylaxis results in an increased overall incidence of eclampsia because of more seizures in women with nonsevere gestational hypertension who are not given magnesium sulfate prophylaxis.

LEVEL OF EVIDENCE

II-3.

Cerebral Hemodynamics in Preeclampsia: Cerebral Perfusion and the Rationale for an Alternative to Magnesium Sulfate

Preeclampsia and eclampsia continue to be major causes of maternal death. Currently, approximately 18% of U.S. maternal deaths are attributed to hypertensive disorders and eclampsia, and several hundred women die from eclampsia and its complications every year. In the United States, preeclamptic women have received magnesium sulfate as a seizure prophylaxis agent for 3 decades, and this practice is becoming more widely accepted internationally. In addition to a recognized failure rate, there are financial, logistic, and safety concerns associated with the universal administration of magnesium sulfate. Many institutions in the developing world lack the necessary equipment and expertise to administer the medication, and many preeclamptic patients thus do not receive magnesium sulfate before their first seizure. As effective as it has been in reducing mortality from eclampsia, magnesium sulfate is also associated with appreciable morbidity and mortality from administration errors and magnesium toxicity. The availability of an easily administered, cheap, safe, and orally administered alternative to magnesium sulfate would be welcomed in the developing world and would provide an extremely useful alternative therapy to the current standard of care. Recent advances in the understanding of the pathophysiology of preeclampsia and eclampsia, primarily related to cerebral perfusion and blood flow, could allow us to reduce the seizure rate in treated preeclamptic women even further than what is currently reported. This article deals with the rationale behind the use of labetalol as an alternative to magnesium sulfate for the prevention of eclampsia.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall that hypertensive diseases of pregnancy contribute a significant portion of today's maternal mortality, explain that methods of preventing eclampsia are not applicable worldwide, and state that understanding of the pathophysiology of preeclampsia/eclampsia may assist in developing safe and effective medications that can be used universally.

Eclampsia in Dar es Salaam, Tanzania — incidence, outcome, and the role of antenatal care

BACKGROUND

In order to assess the effectiveness of antenatal care for prevention of eclampsia, a retrospective case-control study was performed at the Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania. All women with eclampsia seen at MNH during 1999-2000 and controls without eclampsia were included.

METHODS

The study used a labor ward database and antenatal cards of eclamptic women and non-eclamptic controls. For each of the 741 eclamptic women who delivered at MNH, two non-eclamptic controls were chosen from the database. For 399 of the eclampsia cases and 420 non-eclamptic controls, the antenatal records could be traced and compared. Main outcome measures. Maternal and perinatal mortality, detection of antenatal risk factors, appropriate referrals, and incidence of eclampsia.

RESULTS

Hospital and population-based incidences of eclampsia were 200/10,000 and 67/10,000, respectively. The case-fatality rate for eclampsia was 5.0% for women who delivered at MNH and 16% for those referred to MNH after being delivered elsewhere. The risk of low birth weight and perinatal death was significantly increased in eclamptic women (odds ratio = 6 and 10, respectively). The screening coverage for signs of pre-eclampsia was >85%, except for proteinuria (33%). Fewer than 50% of the women who developed eclampsia had been referred from the ANC clinic and <10% were admitted to the antenatal ward at MNH before onset of eclamptic fits.

CONCLUSIONS

The current practice of antenatal care is insufficient as a prevention strategy for eclampsia in a low-resource setting with high incidence of eclampsia.

Eclampsia in Scandinavia: incidence, substandard care, and potentially preventable cases

BACKGROUND

Description of incidence, clinical signs, symptoms, and consequences of eclampsia in Scandinavia, and assessment of substandard care and potential preventability.

METHODS

A descriptive cohort study including all women giving birth in a 2-year period (mid-1998-mid-2000) in Scandinavia. Notifications of eclampsia cases were obtained from all obstetric units at 3-monthly intervals. All patient files were reviewed, and systematic audit was performed to identify potentially preventable cases by using predefined criteria.

MAIN OUTCOME MEASURES

Signs and symptoms preceding the eclamptic seizure, the standard of medical care, maternal and perinatal morbidity, and mortality were all recorded. Potentially preventable cases through improved care and cases eligible for primary prophylactic magnesium sulfate (MgSO4) were estimated.

RESULTS

The incidence of eclampsia was 5.0/10,000 maternities (CI = 4.3-5.7/10,000). Eighty-six percent had a diagnosis of pre-eclampsia before the seizure. Nine of 10 had at least one physical complaint before the first seizure, severe headache being the most common symptom, occurring in two-thirds. Most seizures (90%) occurred after admission to hospital. By audit, 89 cases (42%) were classified as having received substandard care. Prophylactic use of magnesium sulfate might have reduced the number of eclampsia cases by 35 (17%).

CONCLUSIONS

Eclampsia occurred mainly in hospital and the majority of women had symptoms heralding the seizure. In retrospect, nearly half of the cases were found potentially preventable by timely intervention, improved medical care, and systematic use of prophylactic treatment with MgSO4.

Maternal cigarette smoking and the risk of pregnancy-induced hypertension and eclampsia

BACKGROUND

Although previous studies have found that maternal smoking decreases the risk of pregnancy-induced hypertension (PIH), the difference of this effect between primiparous and multiparous women has not been well studied and the results of the exposure-response relationships between maternal smoking and PIH are inconsistent. No previous study has specifically examined the relationship between maternal smoking and eclampsia.

METHODS

We analysed data from a population-based retrospective cohort study of 3 153 944 singleton pregnancies in the US. The data were derived from the national linked birth/infant mortality database for 1998. Multiple logistic regressions were used to describe the relationship between cigarette smoking and PIH and eclampsia.

RESULTS

The adjusted odds ratios (ORs) [95% confidence intervals (95% CIs)] for PIH were 0.80 (0.77-0.83) for primiparous women and 0.81 (0.78-0.83) for multiparous women among smokers compared with non-smokers. The corresponding adjusted ORs (95% CIs) for eclampsia were 0.74 (0.66-0.82) and 0.75 (0.68-0.83), respectively. For PIH, the adjusted OR (95% CI) for smokers vs non-smokers were 0.82 (0.79-0.86), 0.81 (0.78-0.83), 0.80 (0.77-0.83), and 0.88 (0.79-0.98), respectively, for 1-5, 6-10, 11-20, and >20 cigarettes per day (test for trend: P = 0.86). The corresponding figures for eclampsia were 0.85 (0.75-0.95), 0.74 (0.66-0.82), 0.68 (0.58-0.78), and 0.73 (0.49-1.04), respectively (test for trend: P = 0.02).

CONCLUSION

Maternal cigarette smoking decreases the risk of PIH and eclampsia, with a significant inverse exposure-response relationship apparent for eclampsia.

Appropriate technology to prevent maternal mortality: current research requirements

Maternal mortality involves a complex mixture of clinical, infrastructural and social issues and will require a multifaceted approach if we are to see meaningful reductions occur. That includes thoughtful attention to appropriate technologies for low-resource countries. An international group of specialists meeting in Bellagio, Italy, in 2003 identified important needs and opportunities related to new and underutilized technologies to reduce pregnancy-related mortality. Research to fill in critical information gaps was a recurrent theme. Research, whether it is for product development, for building the evidence base about effectiveness and safety or for helping refine introduction strategies and guide practice, plays a critical role in the development and widespread use of technologies. Priority research needs related to the five major causes of maternal mortality-haemorrhage, puerperal sepsis, unsafe abortion, pre-eclampsia and eclampsia and obstructed labour-have been identified. Appropriate collaborations of investigators and other stakeholders and adequate financial resources are urgently needed to move the research agenda forward.

Report of 50 cases of eclampsia

AIM

To ascertain the characteristics, clinical features, and maternal fetal outcome in eclampsia in a tertiary referral center with 24 000 deliveries per year.

METHODS

This is a cross-sectional study, in which 50 case notes were retrieved retrospectively and data was analyzed descriptively.

RESULTS

Eclampsia was significant in the Malay primipara patients (n = 14, P = 0.034) and the 20-24-year-old primipara patients (n = 11, P = 0.01). Most were significantly antepartum (64%) and preterm seizures (68%), and 16% were early onset (<31 weeks). Two-thirds were booked and one-third were inpatients. Twenty per cent did not have hypertension or pre-eclampsia antenatally. Most presented with headache (66%) and hyper-reflexia (48%). Only 16% presented with all three prodromal symptoms and 14% were asymptomatic. Half had diastolic blood pressure (DBP) of <110 mmHg and the level of DBP was not significantly associated with the presence of prodromal symptoms and signs. There was increased morbidity, operative intervention, admission to intensive care and more low birth weight babies. Most babies that weighed <2.5 kg had poor Apgar score at 1 min, but most babies had good Apgar score at 5 min (16 babies >2.5 kg, 22 babies < or =2.5 kg, P = 0.006). The corrected perinatal mortality was 40/1000.

CONCLUSION

There was increased maternal and perinatal morbidity but no maternal mortality. Contributing factors are the atypical presentation, early onset of disease and the absence of risk factors. There is a need to develop new methods to identify this group of patients in an effort to further reduce the prevalence of this dangerous condition.

[Magnesium sulfate in obstetrics: current data]

OBJECTIVE

To review the available evidence regarding history, pharmacology, physiology, maternal/fetal side effects, and efficacy of magnesium sulfate in pregnant women.

DATA SOURCES

The literature in Medline was searched from 1966 through April 2003 using the terms "magnesium sulfate," "tocolytic," "preeclampsia," "eclampsia," and "pregnancy." Reviews of bibliographies of retrieved articles provided additional references.

RESULTS

Magnesium sulfate (MgSO4) has long been used for prophylaxis of preterm delivery (tocolytic affect) and eclampsia prophylaxis (neuroprotective effect). Randomized controlled trials and systematic reviews have demonstrated the efficacy of magnesium sulfate in preventing eclampsia in patients with preeclampsia or in patients with eclampsia. Whether magnesium sulfate should be administered to patients with severe preeclampsia or to mild preeclampsia is discussed in the manuscript. Inversely, it appears that magnesium sulfate is ineffective in delaying birth or preventing preterm birth when it is used as a tocolytic. Furthermore, there is evidence that high cumulative doses of magnesium sulfate may be associated with increased infant mortality.

CONCLUSION

The evidence to date confirms the efficacy of magnesium sulfate therapy for women with eclampsia and preeclampsia. However, magnesium sulfate should not be used in order to treat preterm labor.